EAPG IMPLEMENTATION OBSERVATIONS FROM THE FIRST SIX MONTHS

Transcription

1 February 15, 2018 EAPG IMPLEMENTATION OBSERVATIONS FROM THE FIRST SIX MONTHS Jackie Nussbaum, MHA, CPC, FHFMA Director

2 AGENDA & OBJECTIVES Overview of EAPGs Observations & Reminders ODM & Managed Care Plan Issues EAPG Payment Exceptions EAPG Payment Monitoring & Analysis OHA & BKD Monitoring Project Update 2

3 OVERVIEW OF EAPGS Outpatient claims classification system developed by 3M Accommodates all patients, not just Medicare population Uses discounting, packaging & consolidation Uses CPT/HCPCS & ICD-10 Diagnosis Codes Weights and rates set by Ohio Department of Medicaid nformation/hospitalpaymentpolicy.aspx# outpatient-relativeweights Went live August 1,

4 OVERVIEW OF EAPGS: EAPG DEFINITIONS OP Claim A claim that represents services rendered to one eligible Medicaid beneficiary on one date of service OP Invoice A claim that represents services rendered to one eligible Medicaid beneficiary on one or more date(s) of service Procedure Code Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) 4

5 OVERVIEW OF EAPGS: EAPG DEFINITIONS Packaging The inclusion of payment for certain services within payment for significant procedure or medical services Discounting A reduction in the standard EAPG payment rate when multiple significant procedures are performed Consolidation When a patient has multiple related significant procedures performed on the same date 5

6 OVERVIEW OF EAPGS: MODIFIERS Impact to Payment No Impact to Payment 25 distinct service GN, GO & GP therapy modifiers 27 multiple E&M encounters Anatomical/Select Modifiers (RT, LT, TA, T1, E1, F5, etc.) 50 bilateral procedure Distinct Procedure Modifiers (XE, XS, XP, & XU)* 59 separate procedure 52 reduced service 73 & 74 - terminated surgery PA, PB & PC never event * = BH Redesign 6

7 OHIO POLICY DECISIONS: PAYMENT FORMULA A B C $ A = Hospital specific base rate adjusted for risk corridors B = EAPG relative weight C = Applicable discounting factor(s) $ = Payment (rounded to the nearest penny) 7

8 OBSERVATIONS & REMINDERS ODM & Managed Care Plan Issues Improper payments Consolidating & discounting issues Pharmacy fee schedule issues Mass adjustments Reminders 3M Grouper Payment Exceptions 8

9 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Laboratory Services Codes 36415, 36416, 78267, and/or Reimbursed the LESSER OF charges or the assigned EAPG payment Radiology Services Codes , and/or Reimbursed the LESSER OF charges or the assigned EAPG payment 9

10 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Pharmaceuticals Reimbursement for outpatient hospital pharmaceuticals will be LESSER OF the charge or payment amounts from the provideradministered pharmaceutical fee schedule, when applicable Discounting factors apply Pharmaceutical line items without a National Drug Code will be denied payment by the department provider-administered-pharmaceuticals 10

11 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Durable Medical Equipment (DME) Additional payments for DME may be made for all line items grouping to EAPGs Reimbursement will be the LESSER OF the charge or payment amounts from the DME fee schedule Discounting factors still apply tes.aspx# durable-medical-equipment 11

12 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Dental Services EAPGs will have a special rate applied to calculate reimbursement during the interim period Interim Period - the initial time after EAPG implementation when data collection will occur to determine EAPG relative weights. The interim period will be the effective date of this rule and will last at least six months Children s Hospitals = $1,062 All other Hospitals = $1,192 Discounting factors apply 12

13 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Designated Free Vaccines Immunizations covered under the Vaccines for Children (VFC) program & non-designated vaccines (OAC ) Reimbursement for immunizations under the VFC program are $10 for patients 18 years old or younger, contingent upon EAPG grouper Discounting factors apply tes.aspx# provider-administered-pharmaceuticals 13

14 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Observation Services Need to bill HCPCS G0378 Payment for G0378 will be made using an average rate during the interim period. EAPGs 00450, 00500, & limited to one per day with maximum of two consecutive days Payments will be made on G0378 for up to 24 units per day or 48 consecutive units (could extend over 3-day period) Discounting factors apply 14

15 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Independently Billed Services Drugs or Medical Supplies & Devices Hospital must initiate request for independently billed payment Report all services provided on the date of service UB modifier on primary procedure Payment made on independently billed item; all other lines paid zero 15

16 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Independently Billed Services Drugs or Medical Supplies & Devices Supplies & Devices 027X With or without HCPCS 60% of your specific Medicaid outpatient cost-to-charge ratio 16

17 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Independently Billed Services Drugs or Medical Supplies & Devices Drugs Scenario #1 025X or 636 With J-code or Q-code HCPCS listed in provider-administered pharmaceutical fee schedule Paid according to Fee Schedule Drugs Scenario #2 025X No HCPCS 60% of your specific Medicaid outpatient cost-to-charge ratio 17

18 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Independently Billed Services Drugs or Medical Supplies & Devices Drugs Scenario #3 025X or 636 J-code HCPCS, except J0714, not listed in provider-administered pharmaceutical fee schedule -OR- listed as by report in the fee schedule 60% of your specific Medicaid outpatient cost-to-charge ratio Drugs Scenario #4 025X or 636 Q-code HCPCS not listed in provider-administered pharmaceutical fee schedule DENIED CLAIM 18

19 OHIO POLICY DECISIONS: EAPG PAYMENT EXCEPTIONS Behavioral Health (BH) & Substance Use Disorders (SUD) A hospital claim for BH or SUD services must contain: Modifier HE for each CPT/HCPCS code Revenue Code 0671, 0900, 0904, 0906, 0907, 0911, 0912, 0913, 0914, 0915, 0916, 0918, 0919 or 1002 Diagnosis Code for BH or SUD Reimbursement for BH or SUD will be paid the lesser of charges or the behavioral health fee schedule 19

20 EAPG PAYMENT MONITORING & ANALYSIS Payment monitoring and analysis are crucial Are you getting paid what you expected? Over and under payments Risk corridors If not getting paid what you expected: Correct 3M Grouper settings Including all CPT/HCPCS codes Correct diagnosis coding Correct modifiers Payment exceptions 20

21 SUMMARY OF OHA & BKD MONITORING PROJECT OHA & BKD have partnered to offer monitoring for: Enhanced Ambulatory Patient Groups (EAPG) Implementation Biennium Budget Using 837 (claim) & 835 (remit) files Two-year monitoring time frame July 1, 2017 July 31,

22 SUMMARY OF OHA & BKD MONITORING PROJECT EAPG Monitoring Outpatient payment methodology transition from fee-for-service to EAPGs Claims and remits for Traditional Medicaid & Managed Care Plans Utilize 3M EAPG Core Grouping Software Biennium Budget Monitoring Proposed $1 Billion cut to hospitals during budget Inpatient and Outpatient Claims Claims and remits for Traditional Medicaid & Managed Care Plans 22

23 WHY MONITORING IS IMPORTANT EAPG Monitoring Outpatient reimbursement methodology shift from fee-forservice to a prospective payment methodology Caveats to the EAPG methodology during the interim period Opportunities and potential pitfalls for reimbursement Risk corridors Stop loss/stop gain risk corridor of 0-5 percent 23

24 WHY MONITORING IS IMPORTANT Biennium Budget Monitoring Proposed $1 Billion in cuts to hospitals from Cuts on both inpatient and outpatient reimbursement Timely Medicaid budget spend reporting to OHA and the Ohio Department of Medicaid (ODM) Potential to delay and/or prevent cuts through monitoring 24

25 MONITORING PACKAGES: BASE VS. OPTIONAL Base Package Contract directly with OHA Includes the following: EAPG reimbursement and risk corridor monitoring Budget monitoring (Inpatient and Outpatient claims) Eight quarters of reporting over two-year time frame Optional Package Contract directly with BKD Includes the following: EAPG reimbursement analysis for high cost drugs & supplies, lesser of language, flat rate reimbursed services, observation, etc. Payer analysis for your hospital compared to your peer group Eight quarters of reporting over two-year time frame 25

26 CURRENT PROJECT STATUS OHA has contracted with close to 100 Ohio hospitals for the EAPG base package BKD working closely with hospitals and health systems to obtain the claim and remit information needed for the project Summary package delivery dates subject to getting contracts signed and obtaining claim and remit data BKD issuing engagement letters to interested hospitals for the optional package 26

27 QUESTIONS?

28 THANK YOU! FOR MORE INFORMATION Jackie Nussbaum